1. Tuberculosis (TB) Fundamentals for School Nurses

2. Transmission and Pathogenesis of TB
Caused by Mycobacterium tuberculosis (tubercle bacillus)
Spread through the air by inhaled droplet nuclei
Prolonged contact needed for transmission
Transmission can occur from an infectious TB case by coughing, sneezing, laughing, or singing
TB most common in lungs (85%), but can occur in other parts of the body (extrapulmonary)

3. TB in Children TB is more prevalent in adults
In children, TB is more serious than in adults
Young children, especially under the age of 4, have difficulty fighting off infections & can have serious forms of TB if left untreated
Treating latent TB infection can prevent the child from getting active TB disease in the future

4. TB Infection vs. TB Disease

5. Symptoms of TB Disease Prolonged cough (may produce sputum)*
Chest pain*
Hemoptysis*
Fever
Chills
Night sweats
Fatigue
Loss of appetite
Weight loss/failure to gain weight
*commonly seen in cases of pulmonary TB

6. Infectiousness
Children have few tubercle bacilli in lungs, therefore, are rarely infectious
Children less than 12 years of age usually lack the pulmonary force to produce airborne bacilli
For a case of childhood TB infection, it is likely that an adolescent or adult transmitted TB bacilli to the child; it is important to find the source case

7. Recommendations for Skin Testing
The American Academy of Pediatrics recommends targeted TB skin testing only in areas of high TB prevalence
Routine skin testing does not need to be done in low prevalence areas
Consult with your school district and health department for local skin testing guidelines
School nurses may be required to administer skin tests or read results of a skin test for a physician

8. Tuberculin Skin Testing (TST) - 1
TST used for detection of TB infection
Use Mantoux method not multiple-puncture method (e.g. Tine test)
If a child has a documented history of a previously positive skin test, school nurse should inquire about history of treatment completion:
If no documented history of treatment completion is present, child should be referred to the health department
If documented treatment completion history is present, the child need not be skin tested nor chest X-rayed again; should be instructed to watch for signs and symptoms of TB in the future

9. Tuberculin Skin Testing (TST) Administration*
Use 5 TU purified protein derivative (PPD) tuberculin
Intradermally inject 0.1 cc of tuberculin into arm forming 6-10 mm wheal
Have child come back for reading hours later
* detailed method can be found in Tuberculosis School Nurse
Handbook

10. Tuberculin Skin Testing (TST) Reading and Interpretation
Measure only transverse induration (hardness, not erythema (redness) or bruising)
Document result with a millimeter reading (not just as ‘negative’ or ‘positive’)
Use school district/health department guidelines for medical evaluation and referral for a positive result

11. BCG Vaccine
BCG vaccine is used in parts of the world where TB is highly prevalent
It may cause a false-positive skin test result, however, there is no way to distinguish a false-positive from true infection
If a child has a history of having received BCG vaccine & has a positive skin test result, (s)he should be referred for a medical evaluation, as per school district/health department guidelines

12. Diagnosis of TB - 1
If a child has a positive skin test (s)he should have a chest X-ray and medical examination for symptoms of TB
If the chest X-ray is negative and the child is asymptomatic, the child should be evaluated for treatment of latent TB infection

13. Diagnosis of TB - 2
If chest X-ray and skin test are both positive and/or TB symptoms are present, sputum or other site specific specimen should be collected
Specimen smear results may show acid fast bacilli (TB-like bacilli)
True confirmation of TB is through culture (growing M. tuberculosis) from the specimen

14. TB Treatment
If TB is suspected, prior to receiving TB culture results, treatment must be initiated
There are four first-line TB drugs:
Isoniazid (INH)
Rifampin (RIF)
Pyrazinamide (PZA)
Ethambutol (EMB)

15. Usual Pediatric Treatment Regimens
Diagnosis
Treatment
TB Infection
INH – 9 Months
TB Disease
3 or 4 drugs
First 2 months – INH, RIF, PZA, EMB (add EMB if drug resistance is suspected)
Next 4 months – 2 most effective sensitive rugs (INH & RIF in pansensitive cases)
Multidrug resistant TB disease (resistance to at least INH & RIF)
Treat with sensitive drugs (varies) for at least 18 months

16. Directly Observed Therapy (DOT)
DOT is the watching of the ingestion of anti-TB medications by a trained outreach worker or healthcare worker
DOT cannot be administered by a family member

17. School-Based DOT School nurse can administer DOT in school
Clinician will provide regimen for nurse to follow
School nurse can give feedback to clinician on frequency of dosing that works well for child (medication must be given only once a day, but can vary the amount of times per week as per physician order)
School nurse can also provide feedback on child’s medical condition

18. Administering TB Medication in School -1
As with all medical conditions, there should be confidentiality surrounding taking medications
You cannot contract TB from administering medications to a child with TB, as an infectious child will not be sent to school
Administer medication in a private area at a time convenient to the child

19. Administering TB Medication in School - 2
Notify the physician of problems if the child:
Is absent for prolonged period of time
Is frequently missing doses of medication
Has side effects or adverse reactions
Has symptoms which do not improve or improve and then suddenly return

20. Challenges in Medication Administration - 1
School absences/vacations - make arrangements ahead of time
Have the child’s parent/guardian inform you directly of a pending absence
In case of absence/vacation see if health department can provide DOT
If you are absent, arrange for substitute nurse to administer medications

21. Challenges in Medication Administration - 2
“No show” for medications
Discretely, check if child is absent and then institute absentee plan
Avoid forgetfulness by choosing a convenient time for medication administration such as before school or lunchtime

22. Challenges in Medication Administration - 3
Difficulty swallowing medications
If you must, use food to mix medications with and vary food choices periodically
Use the smallest amount of food possible to mix medications in
Pills can be crushed and capsules can be opened and the contents mixed with food

23. Challenges in Medication Administration - 4
Lack of understanding and incentive
You should constantly reinforce the importance of taking anti-TB medications as prescribed
Refer concerns to the physician
Provide positive feedback and small rewards to the child for successfully completing medication

24. Challenges in Medication Administration - 5
Lack of time
Consider flexible scheduling so that children with varying medical needs can come for care at different times throughout the day
Prioritize certain children’s regimens that cannot be adjusted easily

25. Challenges in Medication Administration - 6
Lack of time, cont’d
Although TB medications are given only once a day, they should be given at the same time each day and dose cannot be split
With clinician order, intermittent therapy may be possible (administering medication 2-3x per week as opposed to daily)

26. Caring for child with TB is an important responsibility whether the child has infection or disease. The school nurse’s role is important in controlling TB rates in this country.